Hindawi Case Reports in Obstetrics and Gynecology Volume 2017, Article ID 4807013, 3 pages https://doi.org/10.1155/2017/4807013

Case Report in the Axillary Accessory Mimicking Suspicious Solid Mass on Ultrasound

Donya Farrokh, Ali Alamdaran, Farhad Yousefi, and Bita Abbasi

Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Correspondence should be addressed to Bita Abbasi; [email protected]

Received 3 February 2017; Accepted 27 March 2017; Published 9 April 2017

Academic Editor: Eing Mei Tsai

Copyright © 2017 Donya Farrokh et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Galactoceles are the most common benign breast lesions during breastfeeding period that can mimic carcinomas. We report a galactocele with malignant appearance on ultrasound in the . The patient was a 32-year-old lactating woman presented to our hospital for considerable swelling in the left axilla. Ultrasound examination revealed a hypoechoic mass with heterogeneous echogenicity and irregular shape and margins. Sonography-guided aspiration was performed. Aspiration of milky fluid and resolution of the axillary lump after aspiration confirmed the diagnosis of galactocele. Galactocele can presentasa suspicious tumoral lesion in the axillary accessory breast and diagnostic aspiration can help in correct diagnosis of this rare lesion in the accessory breast.

1. Introduction 2. Case Presentation Accessory axillary breast is a congenital anomaly that is A 32-year-old woman who was breastfeeding her first baby for commonly bilateral and does not include areola and 6 months, presented to our Breast Clinic with the complaint in most cases. The diagnosis of accessory breast tissue may be ofapalpableleftaxillarylump.Shehadnoticedalumpin delayeduntilthefirstpregnancy,whenhormonalfluctuations her left axillary region before the pregnancy, which became change the breast composition [1, 2]. In the pregnancy enlarged during the pregnancy and breastfeeding periods. period, symptomatic axillary breast tissue becomes painfully Physical examination revealed a 4 cm mass in the subcu- enlarged and a galactocele may rarely develop [2]. Galacto- taneous tissue of the left axilla. The mass was nontender and celes can be caused by any etiology that blocks a breast duct unattached to skin. There were no evidences of inflammation during lactation, but, in most cases, it is the result of a benign such as skin color discoloration in the left axilla or fever. condition. Ultrasound examination of the axillary region revealed a are similar to ordinary cysts, but, instead of hypoechoic, well-defined mass with irregular shape and clear fluid, they contain milk. They can mimic , margins and nonparallel orientation measuring 2.5 ∗ 3.5 ∗ carcinoma, and other breast masses [3]. The mammographic 4 cm which was suspicious for a malignant lesion (Figure 1). and sonographic appearances of a galactocele depend upon Color Doppler ultrasound was performed and did not the amount of fat in the fluid, the viscosity of the fluid, show vascular flow in the axillary mass. Ultrasound exam- and also the amount of proteinaceous material. Aspiration ination of the left breast did not reveal any significant of milk will generally confirm the diagnosis. Here, we report abnormality and lymphadenopathy was not seen in the axilla. a case of galactocele in the accessory axillary breast tissue There was no significant abnormality at the right breast masquerading a suspicious solid mass. The presence of and axilla except for the proliferative changes of glandular galactocele was confirmed after fine needle aspiration (FNA) tissuewhichisanormalfindingduringlactationandwasseen of the axillary mass. in both . 2 CaseReportsinObstetricsandGynecology

Figure 1: Ultrasound examination of the axillary mass reveals a hypoechoic mass with irregular margins.

Figure 3: Proliferative changes in the accessory breast tissue in the axillary region. There is no evidence of mass lesion.

Although it is most commonly located in the axilla, Figure 2: A milky fluid was aspirated with fine needle aspiration of ectopic or accessory breast tissue may be seen anywhere the axillary mass. along the thoracoabdominal milk line. This line extends from the axillary region down to the groin [6]. Axillary accessory breast usually presents as bilateral swellings in the axilla. Considering that the patient was in breastfeeding period, Various lesions have been reported in the accessory breast our first diagnosis was a galactocele in the accessory breast, in the literature including simple cyst, inflammatory lesions but because the sonographic appearance of the axillary mass and , atypical hyperplasia, fibroadenoma, and rarely was not consistent with the ultrasound criteria of a true carcinoma [1]. simple cyst or a typical benign lesion, both the clinician Galactoceles are the most common benign breast lesions and the patient were concerned and insisted on performing in lactating women [2, 3]. Galactoceles can mimic fibroade- an interventional procedure to rule out possible malignant noma or breast carcinoma, but they are always benign and do nature of the lesion. Ultrasound-guided aspiration using a 20- not increase the risk of in any way. Galactoceles gauge needle was performed for confirming an axillary galac- may have several causes. Three main factors are required tocele. Milky fluid was aspirated and the mass disappeared to make a galactocele including secretory breast epithelium, completely (Figure 2). present or previous prolactin stimulation and ductal obstruc- The aspirated materials were sent for laboratory evalua- tion. Breast surgery, oral contraceptives, and transplacental tion. Cytopathologic examination was negative for malignant prolactin passage are reported as other possible causes in cells. Based on these findings, the diagnosis of a galactocele of creating a galactocele [3]. the axillary accessory breast was made. Clinically, the mass is usually firm and nontender and presents as a tumoral lesion on physical examination. The Additional diagnostic investigations were not indicated patientusuallynotesthelesionduringlactationorsome in our patient and she was reassured to have a follow-up period after lactation [2, 3]. sonographic examination after 3 months. She returned 4 The imaging appearance of galactocele depends on the months later and ultrasound examination was performed. amount of fat and proteinaceous material present in the cystic There was no evidence of any left axillary mass and accessory lesion and also the viscosity of the fluid. Pseudolipoma is the breast tissue with proliferative changes was noted (Figure 3). name given to the galactocele when the fat content is very high and appears as a completely radiolucent mass [7, 8]. 3. Discussion The typical mammographic features of galactocele are a mass with fat-fluid level caused by fat and water. Fat-fluid levels are Galactoceles are benign lesions of the breast that represent usually seen on the mediolateral mammographic view with encysted collections of milk products. They are mostly the patient in upright position and a horizontal X-ray beam detected during lactation or in the third trimester of preg- [2]. nancy. However, in rare cases, the condition may occur after The interpretation of is usually difficult breastfeeding has stopped, as milk is retained and becomes in young woman particularly during breastfeeding period stagnantwithinthelactiferousducts[1,3,4].Thepresenceof as mammography is usually very dense in these women. galactoceleinadultmalesandyounginfantshasbeenrarely Ultrasound is the imaging method of choice to evaluate breast reported [2, 4]. The presence of galactocele in the axillary masses during pregnancy and lactation and mammography accessory breast is a rare occurrence [4, 5]. should be performed only in special circumstances [7, 8]. Case Reports in Obstetrics and Gynecology 3

The ultrasound appearance of galactocele also depends sonography,” JournalofUltrasoundinMedicine,vol.25,no.2, on the amount of fat and water contents. Galactoceles with pp. 145–151, 2006. various amount of old milk, water, and proteinaceous mate- [4] J. H. Yu, M. J. Kim, H. Cho, H. J. Liu, S. J. Han, and T. G. Ahn, rials may present as a heterogeneous mass with a pseudo- “Breast diseases during pregnancy and lactation,” Obstetrics & solid appearance, containing hypoechoic and hyperechoic Gynecology Science,vol.56,no.3,pp.143–159,2013. materials or a complicated cyst-like lesion mimicking breast [5] F. M. Hall, “Galactocele: three distinctive radiographic appear- cancer, but well-defined and distinct margins would suggest ances,” Radiology,vol.160,no.3,pp.852–853,1986. a benign lesion [3, 7]. [6] P.P.Patel, A. M. Ibrahim, J. Zhang, J. T. Nguyen, S. J. Lin, and B. Salvador et al. reported a wavy line separating the mass T. Lee, “Accessory breast tissue,” Eplasty,vol.12,articleic5,2012. into hyperechoic and hypoechoic portions or fat-fluid level [7]S.Joshi,V.Dialani,J.Marotti,T.S.Mehta,andP.J.Slan- [9]. Kim et al. reported that, in their series, about 4.6% etz, “ in the pregnant and lactating patient: of breast masses with BI-RADS category 4 on ultrasound radiological-pathological correlation,” Insights into Imaging,vol. in women during breastfeeding period were proven to be 4, no. 5, pp. 527–538, 2013. galactocele after performing core needle biopsy [3]. In rare [8] J. M. Sabate, M. Clotet, S. Torrubia et al., “Radiologic evaluation instance when galactocele presents as a solid tumor, multiple of breast disorders related to pregnancy and lactation,” Radio- differential diagnosis including benign fibroadenoma and graphics,vol.27,supplement1,pp.S101–S124,2007. invasive carcinoma should be considered [3, 10]. In general, [9]R.Salvador,M.Salvador,J.A.Jimenez,M.Martinez,andL. an ultrasound-guided fine needle aspiration (FNA) and/or Casas, “Galactocele of the breast: radiologic and ultrasono- core needle biopsy should be performed if a lesion does graphic findings,” British Journal of Radiology,vol.63,no.746, pp.140–142,1990. not have the typical imaging appearance of galactocele or a benign breast lesion in a lactating woman [2, 11]. [10] S. Goyal, T. Puri, R. Gupta, P. Julka, and G. Rath, “Accessory Milk aspiration can be performed and cyst resolution breast tissue in axilla masquerading as breast cancer recur- rence,” Journal of Cancer Research and Therapeutics,vol.4,no. following aspiration can be a pathognomonic sign of a galac- 2, pp. 95–96, 2008. tocele. Galactoceles are not serious or dangerous but may be [11] A. E. Swinford, D. D. Adler, and K. A. Garver, “Mammographic uncomfortable. The typical treatment for a galactocele is to appearance of the breast during pregnancy and lactation: false leave them alone. Galactoceles usually resolve spontaneously assumptions,” Academic Radiology,vol.5,no.7,pp.467–472, after the hormonal change associated with pregnancy and 1998. lactation is ceased. But, in patients with true discomfort, attempts may be made to drain the galactocele through FNA. Some clinicians have proposed that the diagnostic aspiration of the fluid from the cystic mass may prove to be diagnostic and therapeutic at the same time [2]. In conclusion, the presence of galactocele as a mass in accessory axillary breast tissue is a rare occurrence but that should be kept in mind in pregnant or lactating women pre- sentingwithaxillarymass.Galactoceleslocatedintheaxillary accessory breast may rarely appear as a solid suspicious mass mimicking a malignant lesion. In most cases, FNA usually confirms the correct diagnosis and can be used as a diagnostic and also a therapeutic test in these patients.

Conflicts of Interest The authors declare no conflicts of interest.

Acknowledgments The authors thank Mashhad University of Medical Sciences for their valuable support.

References

[1] K. E. Greer, “Accessory axillary breast tissue,” Archives of Dermatology,vol.109,no.1,pp.88–89,1974. [2]I.Y.Whang,J.Lee,andK.T.Kim,“Galactoceleasachanging axillary lump in a pregnant woman,” Archives of Gynecology and Obstetrics,vol.276,no.4,pp.379–382,2007. [3]M.J.Kim,E.-K.Kim,S.Y.Park,H.K.Jung,K.K.Oh,andJ. Y. Seok, “Galactoceles mimicking suspicious solid masses on M EDIATORSof INFLAMMATION

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